Associative functional analysis model

of posttraumatic stress disorder

Nenad Paunović, Department of Psychology, Stockholm University, Stockholm, Sweden

Temporary address:
Traumacenter (house 27)
Danderyds hospital
182 88 Danderyd
Sweden
Phone: +46-(0)8-655 79 34
E-mail. sonepaunovic@hotmail.com
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Abstract

A revised associative functional analysis (AFA) model of posttraumatic stress disorder

(PTSD) is outlined. In terms of the AFA model currently elicited respondent mechanisms, and

dysfunctional cognitive and behavioral responses reciprocally influence each other, and

interact with a representational memory network of corresponding factors in determining the

development and maintenance of PTSD. The present AFA model combines cognitive,

behavioral and network models into a unified framework. In the present AFA model a special

emphasis is put on the influence of pleasurable and mastery respondent learning mechanisms

incompatible to the respondent trauma-related learning. It is proposed that in order to achieve

recovery the former should be elicited in the context of fully elicited trauma-related

respondent mechanisms. Prolonged exposure counterconditioning (PEC), a new treatment for

PTSD, aims at reinforcing an individuals incompatible respondent learning mechanisms and

utilizing them in order to counter the numbing symptoms, increase the trauma exposure

tolerance and weaken respondently learned trauma-related emotions. Important theoretical

and methodological issues related to the PEC treatment are reviewed. In the discussion

section additional issues related to the present AFA model and the PEC treatment for PTSD

are outlined.

Keywords: associative functional analysis, prolonged exposure counterconditioning, PTSD,

theory, treatment.
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Introduction

Cognitive-behavioral conceptualizations of posttraumatic stress disorder (PTSD) have

led to the development of cognitive-behavioral therapies (CBT) that have shown good

treatment efficacy for this disorder (e.g., Foa et al., 1999; Keane, Fairbank, Cadell, &

Zimering, 1989; Resick, Nishith, Weaver, Astin, & Feuer, 2002; Rothbaum, Meadows,

Resick, & Foy, 2000). Cognitive-behavioral models usually focus on correcting dysfunctional

cognitive schemas, fear structures in memory, and catastrophic interpretations that are

postulated to maintain PTSD (e.g., Ehlers & Clark, 2000; Foa & Rothbaum, 1998; Resick &

Schnicke, 1992). In behavioral models negative reinforcement is the primary mechanism that

maintains PTSD (e.g., Keane, Zimering, & Cadell, 1985). However, potential limitations of

these CBT models include the following. First, since cognitive models postulate that cognitive

mechanisms are maintaining PTSD potential maintaining influences of the current

environment are not included. Second, in both CBT and behavioral models respondent

mechanisms are not viewed as contributing factors in the maintenance of PTSD, despite the

use of CBT procedures that supports a respondent conceptualization. For example, breathing

retraining and relaxation procedures constitute necessary parts of exposure-based empirically

supported treatments for PTSD that are utilized in order to counter trauma-related anxiety and

fear (Foa & Rothbaum, 1998; Lyons & Keane, 1989). In addition, extinction and habituation

during exposure therapy may often not be due to a decline of trauma-related distress during

trauma exposure, but to the therapist soothing the client after trauma exposure.

Foa and colleagues have adopted the emotional processing theory in order to explain

the maintenance of PTSD (Foa & Rothbaum, 1998; Foa, Steketee, & Rothbaum, 1989). Foa

and Rothbaum (1998) describe a pathological trauma memory structure as characterized by

erroneous associations between stimuli, responses and their meaning. In addition, extreme

positive or negative pre-trauma schemas, and erroneous post-trauma schemas of the self and
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others characterize it. In order for emotional processing to occur so that the erroneous

characteristics of the trauma memory can become modified, a close match between the

arousal at the time of the event and the arousal activated during therapy should be

accomplished (Foa et al., 1989). In addition, new information that is incompatible to the

elements in the fear network must be integrated. Such integration may be indicated by a

physiological habituation within and between the sessions and a normal trauma memory (Foa

& Rothbaum, 1998). This theoretical model has a couple of potential limitations. First, since it

is a cognitive schema model it doesn’t include environmental operants as important

contributors to the maintenance of PTSD. Second, respondent mechanisms are not viewed as

potential maintaining factors in PTSD. Third, it is not clear whether or how the mechanism of

negative reinforcement that was viewed as a factor involved in the maintenance of PTSD

(e.g., Foa & Rothbaum 1998) is integrated with the pathological trauma memory model.

Postulated cognitive and behavioral mechanisms should be parsimoniously integrated into a

unified theoretical model.

The first aim of the present paper is to present a revised associative functional analysis

(AFA) model of PTSD. The AFA model integrates respondent, cognitive, behavioral, and fear

network models in PTSD into a unified framework. It is postulated that each of these

mechanisms has a reciprocal influence on each other. However, in the current presentation of

the AFA model special emphasis is put on the role of respondent learning mechanisms in the

maintenance and recovery of PTSD. First, in order for recovery to occur the currently elicited

trauma-related respondent mechanisms must match the most central trauma-related

respondent mechanisms represented in a memory network of the traumatic experience.

Second, incompatible respondent mechanisms consisting of learned pleasurable and mastery

experiences must be fully elicited in the context of fully elicited trauma-related respondent

mechanisms so that the former can weaken the latter. Respondent and operant learning
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mechanisms that are applied in the present AFA model have been adopted from Baldwin and

Baldwin’s (1986) and Sundel and Sundel’s (1999) material. The second purpose of the

present paper is to outline important theoretical and methodological issues of prolonged

exposure counterconditioning (PEC), a new treatment for PTSD that is based on respondent

re-learning mechanisms according to the AFA model. In PEC pleasurable and mastery

experiences are imaginally relived in order to counter the numbing symptoms, strengthen the

trauma exposure tolerance and respondently weaken the trauma-related respondent learning of

fear, anxiety etc. It is also postulated that incompatible respondent mechanisms of pleasurable

and mastery experiences can provide a traumatized individual with massive evidence that

contradicts trauma-related dysfunctional beliefs, and lead to a diminishment of avoidance

behaviors if trauma cues don’t elicit distress anymore. Important issues on how to accomplish

theoretical and clinical aims in PEC are outlined.

Associative functional analysis (AFA) model of PTSD

A revised associative functional analysis (AFA) model of PTSD

According to the initial AFA model (Paunović, 2003) it was postulated that

respondent mechanisms determined a traumatized individuals cognitive and behavioral

responses, and that a change in the former would result in a change in the latter. In the present

re-formulated AFA model it is proposed that respondent mechanisms, and cognitive and

behavioral responses have a reciprocal influence on each other. Respondent re-learning may

lead to a functional change in dysfunctional cognitive and behavioral responses. However, a

functional cognitive and behavioral change may not always occur. Conversely, functional

changes in trauma-related cognitive and behavioral responses may not result in a thorough
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trauma-related respondent re-learning. In terms of respondent re-learning mechanisms it is

postulated that two conditions must be met in order to accomplish changes in trauma-related

cognitive and behavioral responses. First, the most central details of the trauma-related

memory must be elicited. Dysfunctional trauma-related beliefs and a strong motivational

tendency to escape from the trauma-related memories and distress should accompany such an

elicitation. Second, incompatible respondent learning experiences that fully contradict the

trauma-related respondent experience, all of the trauma-related beliefs and escape/avoidance

behaviors must be elicited in the context of full trauma response elicitation.

Lang, Bradley and Cuthbert’s (1990) motivational structure of emotion is separated

into an appetitive system (associated with pleasant emotions and appetitive behaviors) and a

defensive system (associated with unpleasant emotion and fight or flight behaviors). The

respondent mechanisms in the AFA model that corresponds to these two motivational

structures of emotion are divided into trauma-related and pleasurable/mastery learning

mechanisms that reciprocally influence each other (see right side of Figure 1).

The interaction between currently elicited respondent mechanisms and a representational

memory network of such mechanisms

It is postulated that a traumatized individuals representational memory network of

dysfunctional trauma-related respondent mechanisms must be fully accessed in order to

accomplish recovery in PTSD. Current trauma cues may not be able to access all relevant

dysfunctional respondent responses in a trauma memory network. Furthermore, current

thoughts about or engagements in valued pleasurable and mastery experiences must be strong

enough in order to counter trauma-related respondent responses. An elicitation of

incompatible pleasurable and mastery experiences in the context of full trauma response

elicitation may lead to recovery if the former is stronger than the latter. It is proposed that
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representations of respondent pre-trauma, trauma, and post-trauma experiences determine in

interaction with representations of incompatible pleasurable and mastery experiences whether

psychopathology or recovery from PTSD will follow. In order to accomplish a recovery from

PTSD it may first be useful to elicit all strong respondently learned pleasurable and mastery

experiences. This may strengthen the trauma exposure tolerance and counter the numbing

PTSD symptoms. Second, the most central respondent trauma cues and responses should be

elicited in the trauma memory network. Third, in order to integrate representations of

respondent trauma-related and pleasurable/mastery experiences the latter should be elicited in

the context of the former. A thorough integration should only be possible if the incompatible

respondent responses have fully weakened the trauma-related responses. If such a process

weakens a trauma-related respondent learning it should be much easier for an individual to

reinforce and maintain pleasurable and mastery experiences in everyday life since the latter

doesn’t become weakened by traumatic intrusions. Pleasurable and mastery experiences may

be elicited in two ways. First, past pleasurable and mastery experiences can be imaginally

relived. Second, a behavioral activation of pleasurable and mastery experiences in the present

time can be pursued in valued directions.

Negative functions of intrusions and trauma-related distress

Trauma-related intrusions may have several negative functions when triggered by

internal or external trauma cues. First, intrusions may punish (a) functional thoughts about

previous pleasurable and mastery experiences, (b) present engagements in valued activities

related to pleasurable and mastery experiences, and (c) functional beliefs about oneself and

other people. Second, intrusions may respondently weaken pleasurable and mastery

experiences if the former occur in situations that elicit the latter. Such mechanisms may lead

to the development and maintenance of numbing symptoms in PTSD. If such respondent

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weakening occurs in a large variety of situations or if it is excessively strong it may lead to

severe numbing symptoms. Third, intrusions may function as discriminative stimuli (a) to

start engaging in avoidance behaviors that may lead to negative reinforcement and a

strengthening of the trauma-related respondent learning, and (b) to catastrophic interpretations

of respondent trauma-related stimuli and responses that may in turn reinforce the latter.

Fourth, intrusions may higher-order condition pleasurable and mastery experiences to

trauma-related distress if the former occurs in circumstances of the latter. In this way

pleasurable and mastery stimuli may become trauma reminders that are to be avoided.

Currently elicited trauma-related respondent stimuli and responses

In order to fulfill PTSD criteria of a traumatic event emotional responses must include

experiences of fear, helplessness or horror during the trauma (American Psychiatric

Association, 1994). However, some individuals may respond with other emotions during a

traumatic experience such as anger or shame (e.g., Brewin, Andrews, & Rose, 2000). These

emotions may become respondently learned and elicited by trauma cues during the trauma

sequel in a similar way as emotions of fear, horror or helplessness. Respondent

representations of pre-trauma experiences of anger, shame, fear etc. may be elicited during the

traumatic experience and may reciprocally influence the trauma-related respondent learning.

Distressing respondent posttrauma experiences may also reciprocally reinforce the trauma-

related respondent learning.

Trauma-related dysfunctional beliefs (e.g., Ehlers & Clark, 2000) exacerbate the

trauma-related respondent learning in PTSD. Catastrophic interpretations may function as

positive reinforcers of currently elicited trauma-related respondent stimuli and responses.

Catastrophic interpretations may become higher-order conditioned to trauma-related distress

and come to function as a respondent trauma cue. The numbing symptoms may also be
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negatively interpreted. Numbing symptoms may be misinterpreted as signs of irremediable

personal inadequacy in a similar way as depressive symptoms. According to Teasdale (1985)

the depressive symptoms of a lack of energy, irritability or loss of interest and affection may

be viewed as signs of selfishness, weakness, or as evidence that a person is a poor wife or

mother. Such interpretations may make the symptoms more aversive and may indicate to the

individual that they are going to be very difficult to control. Thus, negative interpretations of

numbing symptoms may reinforce these symptoms.

Elicitation of most central respondent trauma stimuli and responses

In terms of the AFA model it was stated that one of the conditions that must be met in

order to accomplish full recovery from PTSD was exposure to the most central respondent

trauma-related stimuli and responses. Respondently learned trauma-related physical pain may

be a stimulus type that at times may be difficult to fully elicit by imaginal and in vivo

exposure methods. In order to provide such traumatized individuals with a close match

between the exposure medium that is used in therapy and the respondently learned physical

pain a use of alternative exposure methods may be warranted. Video movie scenes that match

a client’s trauma as perfectly as possible can be utilized as an alternative exposure medium.

Obstacles to current engagements in valued pleasurable and mastery experiences

A behavioral activation in pleasurable and mastery activities/experiences can become

impeded in several ways. Trauma-related intrusions and dysfunctional avoidance and

cognitive responses can dampen thoughts about or engagements in pleasurable or mastery

experiences. Pleasurable or mastery activities may be avoided if they become higher-order

conditioned to trauma-related distress during the trauma sequel. An avoidance of trauma-

reminding pleasurable and mastery activities can become negatively reinforced if the
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avoidance leads to a decrease in trauma-related distress. A lack of pleasurable or mastery

experiences in everyday life may lead to a lack of positive reinforcement. Consequently,

numbing symptoms may become exacerbated. Dysfunctional interpretations of intrusions may

exacerbate the intrusions that in turn may deplete pleasurable and mastery experiences.

Negative interpretations of intrusions during behavioral activation of pleasurable and mastery

experiences may punish an individual’s engagement in valued activities. Negative

interpretations about oneself as an incompetent individual (e.g., ones inability to engage in

pleasurable or mastery activities) may exacerbate the trauma-related distress and the numbing

symptoms. A lack of social or assertiveness skills in valued situations may result in

punishment of valued activities due to the skill deficits. Excessive worries about everyday life

issues may impede the elicitation of trauma-related anxiety and fear (e.g., Borkovec, 1994)

and may dampen or prevent incompatible respondent pleasurable and mastery experiences.

The relationship between trauma-related distress and dysfunctional cognitive and behavioral

responses

The vigor with which individuals with PTSD avoid trauma reminders may be related

to the degree of trauma-related distress that intrusions elicit. Individuals who have more

severe PTSD symptoms seem to be more vigilant in detecting threat cues in advance in order

to avoid them than individuals with less distressing PTSD symptoms (e.g., Leskin, Litz,

Weathers, King, & King, 1997). It is hypothesized that if trauma-related respondent emotional

responses can be weakened by incompatible respondent emotional responses, this should lead

to a decrease in dysfunctional cognitive and behavioral responses. Catastrophic interpretations

in PTSD may be more emotional-laden and negative when the trauma-related respondent

responses are more distressing than if they are less distressing. If trauma-related respondent

emotional responses become weakened by incompatible respondent emotional responses

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catastrophic interpretations of the trauma and its sequel should dissipate. Likewise, avoidance

behaviors should decrease if previously avoided respondent trauma-related stimuli and

responses are no longer emotionally distressing.

Mental defeat as a cognitive or emotional mechanism

Intrusions may be characterized by a repeated reliving of total defeat when an

individual totally gave up in his/her mind during the trauma in terms of thinking about how to

influence the outcome of the event. This cognitive mechanism is named as mental defeat and

is associated with inferior outcome in exposure therapy for PTSD (Ehlers et al., 1998). Mental

defeat may be viewed as a causal cognitive mechanism in the maintenance of PTSD.

However, it is also plausible to view mental defeat as a dependent variable determined by

trauma-related respondent emotional mechanisms established during the event. For example,

mental defeat may be determined by the degree of fear, horror or helplessness that an

individual experiences during a trauma. The stronger the feelings of fear, horror or

helplessness are, the more likely it may be that traumatized individuals perceive themselves to

be completely defeated during the trauma.

Social influences on respondent mechanisms and cognitive and behavioral responses

Social support may protect traumatized individuals from developing PTSD symptoms

(Joseph, Andrews, Williams, & Yule, 1992; Joseph, Dalgleish, Thrasher, & Yule, 1995).

However, the mechanisms responsible for the buffering role of social support are unknown.

Social support may constitute respondent emotional experiences that counter an individual’s

social isolation and feelings of alienation from others. Incompatible social-related emotional

experiences may strengthen a person’s trauma exposure tolerance. Social support experiences
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may provide a traumatized individual with evidence that there are trustworthy people and that

the world is not always a dangerous place.

Individuals with PTSD who live in a hostile and critical environment profit poorly

from cognitive and exposure therapies for PTSD. Tarrier, Sommerfield and Pilgrim (1999)

found that people with PTSD who live with or have close contact with relatives with high

scores on expressed emotion (EE) of high hostility and criticism improve poorly on a range of

PTSD symptom measures. Hostile and critical significant others may have various

dysfunctional influences on the trauma-related respondent learning, avoidance behaviors and

dysfunctional beliefs.

Trauma-related respondent learning mechanisms may be positively reinforced if other

people express negative remarks or behaviors to a traumatized individual when the latter is

experiencing trauma-related fear or anxiety. Conversely, trauma-related respondent

mechanisms may become weakened if other people nurture, verbally praise and show other

respectful and loving behaviors when the traumatized individual experiences trauma-related

fear and anxiety. Respondently learned pleasurable and mastery experiences can become

positively reinforced if other people express positive remarks and behaviors towards a

traumatized victim when the latter is behaviorally or experientially engaging in the

pleasurable and mastery experiences. Conversely, pleasurable and mastery experiences may

become punished if other people express negative remarks and behaviors when a traumatized

individual engages in the pleasurable and mastery experiences.

Other people may positively reinforce a traumatized individual’s avoidance behaviors

and faulty catastrophic interpretations that in turn may lead to a reinforcement of the trauma-

related respondent learning. In addition, significant others may discourage a traumatized

individual from talking about the trauma or exposing him/herself to imaginal or in vivo

trauma cues. Such behaviors may function as punishers to engagements in functional

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approach behaviors towards harmless trauma cues. Other people may also punish a

traumatized individual’s functional interpretations of oneself and others by negative remarks

and behaviors. A punishment of functional behaviors and cognitions may most probably

occur if they are immediately followed by negative remarks from others and if the former

promptly decrease after the negative remarks. Functional approach behaviors and cognitions

may become extinguished if other people consistently ignore them. Functional responses may

abruptly decrease in invalidating environments in which a traumatized individual has learned

that nobody is ever listening to what he/she thinks and feels.

Other people may differentially reinforce dysfunctional respondent, cognitive and

behavioral responses. Functional respondent, cognitive and behavioral responses can be

extinguished (ignored) or punished by negative remarks and behaviors from others. At the

same time, dysfunctional respondent, cognitive and behavioral responses can be positively

reinforced by nurturing behaviors, positive remarks etc. Conversely, other people may

differentially reinforce functional respondent, cognitive and behavioral responses. Functional

respondent, cognitive and behavioral responses can be positively reinforced by positive

remarks and behaviors and corresponding dysfunctional responses can be ignored or

punished.

It is not only the current social environment that may reinforce or punish an

individual’s functional or dysfunctional respondent, cognitive and behavioral response.

Representations of pre-trauma social reinforcing or punishing experiences may be elicited in

an individual’s memory network. The elicitation of punishing experiences in the network may

punish functional respondent, cognitive and behavioral responses. The elicitation of

invalidating experiences in memory may abruptly extinguish functional respondent, cognitive

and behavioral responses. An elicitation of reinforcing experiences in the memory network

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may positively reinforce either dysfunctional or functional responses depending upon in

which contexts the former is elicited.

The real intention of significant others dysfunctional behaviors towards the

traumatized individual may be important to reveal in order to provide the person with realistic

information on why people behave as they do. One possible reason of ignoring a victim or

expressing negative remarks may be to avoid the emotional pain that significant others

themselves experience when reminded of the victim’s trauma. Traumatized people may

erroneously misinterpret such behaviors as indications of that others do not care about them.

On the other hand, if the function of another person’s behaviors is to cause harm to a

traumatized individual, then such a person should correctly be perceived as harmful and

should be avoided.

The impact of pleasurable and mastery experiences on beliefs about the self and others

Currently elicited pleasurable and mastery experiences may determine an individual’s

beliefs about him/herself and others. A high degree of current pleasurable and mastery

experiences may result in functional beliefs of oneself, other people and the world. A low

degree of current pleasurable and mastery experiences may lead to negative beliefs of oneself,

others and the world. An imaginal reliving of past pleasurable and mastery experiences may

increase an individual’s trauma-related functional beliefs. Conversely, a lack of pleasurable

and mastery experiences may result in the maintenance of dysfunctional beliefs in PTSD.

People who lack pleasurable and mastery experiences in their life need to acquire such

experiences in order to combat their dysfunctional trauma-related beliefs. The content of

functional beliefs in PTSD comprise of beliefs of oneself as a worthy and competent

individual, of other people as trustworthy, and of the world as a relatively safe place (e.g., Foa

& Rothbaum, 1998; Resick & Schnicke, 1992). Conversely, dysfunctional beliefs consist of
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beliefs that oneself is an unworthy and incompetent individual, that other people are

untrustworthy, and that the world is an extremely dangerous place.

Pre-trauma pleasurable and mastery experiences

Traumatized people who have had many very pleasurable and mastery experiences

before the index trauma are equipped with incompatible respondent learning experiences that

can be utilized in order to weaken the trauma-related respondent learning. The incompatible

learning experiences can be utilized in order to counter both the trauma-related respondent

mechanisms and the concomitant dysfunctional cognitive and behavioral responses. In

individuals with PTSD an imaginal elicitation of pleasurable and mastery experiences that

occurred before the index trauma may become dampened by intrusions. In addition, people

who have had few pleasurable or mastery experiences before the index trauma may not be

able to elicit strong enough incompatible experiences in therapy. In order to accomplish

recovery from PTSD incompatible respondent experiences should be fully elicited in the

context of fully elicited trauma-related respondent responses. Furthermore, the incompatible

respondent learning must be equally strong or stronger than the trauma-related learning. In

order to make sure that the incompatible experiences are strong enough in order to weaken the

trauma they must first elicit intense enough pleasure or mastery emotions. Secondly, they

should be relived for a prolonged time so that they can weaken the trauma responses and

regain their strength after trauma exposure. Such a process may weaken the trauma-related

respondent learning and strengthen the incompatible respondent mechanisms.

Avoidance and approach behaviors

The function of cognitive and behavioral avoidance behaviors is to decrease trauma-

related distress. The relief that follows successful avoidance behaviors negatively reinforces
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the avoidance behaviors and the trauma-related respondent learning. Trauma-related thoughts,

images and emotions may be suppressed or avoided. Conversations, situations, persons and

activities that remind of the trauma may be avoided. Worries about everyday life issues may

decrease trauma-related distress and lead to a negative reinforcement of the worry and the

trauma-related respondent learning. Worry reduces physiological arousal in response to a

threatening stimulus (Borkovec & Hu, 1990) and has a negatively reinforcing function

(Borkovec, 1994). If substance or drugs abuse is used in order to self-medicate PTSD

symptoms it has an avoidant function.

Since the function of cognitive and behavioral avoidance behaviors is to decrease

trauma-related distress, avoidance behaviors should decrease if trauma-related respondent

distress becomes weakened by incompatible respondent emotions. However, avoidance

behaviors may persist despite that such process has weakened trauma-related respondent

emotions. This may be due to an incomplete weakening of the trauma-related respondent

learning. A test that can be used in order to evaluate the extent of the trauma-related

respondent weakening is to expose the individual with trauma reminders that fully match the

stimulus characteristics of the client’s trauma (e.g., violent video movie scenes that will be

discussed later) and to ask the person to rate the degree of subjective distress (SUDs).

Prolonged exposure counterconditioning

Prolonged exposure counterconditioning (PEC) is a new treatment for PTSD that

utilizes incompatible respondent learning experiences in order to accomplish recovery from

PTSD (Paunović, 2002, 2003). PEC is based on the AFA model and consists of three parts.

First, respondently learned pleasurable and mastery experiences are identified and imaginally

relived for a prolonged time. The purpose is to elicit as strong incompatible emotional
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responses as possible in order to counter the numbing symptoms and to increase the trauma

exposure tolerance. Second, respondently learned trauma responses are elicited during a short

period of time by a trauma exposure to central details. The aim is to fully elicit the trauma-

related emotional responses. Third, when the trauma-related respondent emotional responses

have become fully elicited pleasurable and mastery experiences are imaginally relived for a

prolonged time. The primary purpose is to weaken the respondently learned trauma responses

by incompatible learning experiences. In addition, the respondently learned pleasurable and

mastery experiences are reinforced and the numbing symptoms countered in the context of

weakened trauma-related responses. The purpose of the second part of this paper is to outline

theoretical and methodological issues that are crucial to take into account when the PEC

treatment for PTSD is implemented.

The incompatibility between the pleasurable/mastery reliving and the traumatic experience

The pleasurable and mastery reliving in PEC is incompatible to the traumatic

experience in several respects. First, a pleasurable reliving that is accompanied by low arousal

(e.g., being nurtured by significant others) is physiologically incompatible to anxiety and fear.

Second, a pleasurable reliving that is accompanied by high arousal (e.g., enjoyed sporting

activities, sexual intercourse) is incompatible to the depressive-like numbing symptoms in

PTSD. Third, a pleasurable/mastery reliving is associated with approach behaviors towards

valued activities and social transactions whereas the trauma-related learning is related to an

avoidance of trauma reminders and valued activities that have become associated with the

trauma. Fourth, a pleasurable/mastery reliving provides evidence that supports functional

beliefs including that the individual is a worthy and competent individual, that other people

are trustworthy, and that the world is a relatively safe place. Conversely, the traumatic

experience is associated with dysfunctional beliefs of oneself as a worthless and incompetent

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individual, of others as untrustworthy, and of the world as a very dangerous place (e.g., Foa &

Rothbaum, 1998). Fifth, since PTSD is characterized by an attentional bias towards trauma-

related stimuli (e.g., Williams, Mathews, & MacLeod, 1996) a pleasurable/ mastery reliving

involves an attention to respondently learned experiences incompatible to the trauma. Sixth, a

pleasurable and mastery reliving provides a traumatized individual with evidence that the

person is able to experience valued emotions in the present moment in time. Such emotional

experiences contradict the numbing symptoms. Seventh, a pleasurable/mastery reliving may

increase a client’s positive expectations of the future and motivate the individual to

behaviorally activate him/herself in valued activities and social transactions in everyday life.

Conversely, the traumatic experience may impede positive expectations of the future and may

decrease an individual’s motivation to engage in valued activities and social transactions in

the present moment in time.

Substituting the associative technique with therapist behaviors

In the current version of PEC the previously used associative technique (Paunović,

2002, 2003) has been replaced by specific therapist behaviors that are higher-order

conditioned to the pleasurable and mastery experiences. In the present PEC treatment the

quality of the therapists voice is associated with the pleasurable and mastery experiences in

the client. The therapist utilizes the same voice quality during both the pleasurable/mastery

reliving and the trauma exposure. The purpose of the same voice quality during trauma

exposure is to elicit the traumatized individual’s respondently learned pleasurable responses

in order to increase trauma exposure tolerance, and to positively reinforce the vividness of

central trauma details and the elicitation of trauma responses. The previously used associative

technique consisted of pairing a tactile stimulus (pressing the top of a client’s finger during a

short period of time) to the pleasurable/mastery reliving, and eliciting the tactile stimulus
 19

during trauma exposure. However, this technique may be difficult to disseminate to mental

health professionals and may be experienced as physically intrusive by some trauma

survivors. Also, there is no empirical evidence that supports its usefulness and it is

theoretically plausible to assume that it is not a necessary part of the PEC treatment. In

addition, pressing a client’s finger on repeated occasions may divert the client’s attention to

the tactile sensations during the treatment process.

Increasing the client’s engagement in talking about pleasurable and mastery experiences

It may be important to maximally engage the client in the pleasurable and mastery

reliving. An active engagement on the client’s part in identifying and re-telling pleasurable

and mastery experiences may increase the individual’s sense of self-efficacy (e.g., Bandura,

1997, pp. 321-323). A sense of self-efficacy may constitute mastery experiences that have the

capability of further reinforcing the client’s pleasurable and mastery reliving. Furthermore,

self-efficacy may strengthen a client’s motivation to engage in a continuous search for

potentially more reinforcing experiences. An identification of more reinforcing pleasurable

and mastery experiences may provide the therapist with material that is therapeutically more

useful. Pleasurable and mastery experiences that are increasingly more reinforcing can elicit

increasingly stronger incompatible emotional experiences that can be utilized in order to

weaken the trauma-related respondent learning mechanisms.

A continuous search for increasingly more reinforcing pleasurable and mastery experiences

A client may not initially identify his/her most reinforcing pleasurable and mastery

experiences in lifetime. The utilization of initially identified pleasurable/mastery experiences

should be considered tentative. Any such experience can be replaced by another if the client
 20

or the therapist identifies stronger pleasurable or mastery experiences during the course of

PEC treatment.

The nature of the pleasurable and mastery experiences may have a short or a long time

span. According to the PEC rationale it is crucial to help the client identify and repeatedly

relive peak experiences of pleasure and mastery. Some clients are able to immediately

describe their peak experiences of pleasure or mastery without therapist prompting. Other

clients may need various amounts of therapist prompting in order to identify and relive their

most pleasurable and masterful experiences. If several pleasurable and mastery experiences

occurred during the same day, week or month they may contain a series of pleasurable/

mastery events that may be utilized in PEC treatment. Pleasurable and mastery experiences

may have occurred during specific time periods such as holidays, weddings etc. They may

also have occurred at certain places, with certain people, or in specific situations. Sometimes

it may be useful to ask a client to describe several peak experiences of pleasure or mastery

that occurred in such circumstances. If several very pleasurable and masterful experiences are

identified that are more reinforcing than previously identified experiences they may be

utilized in PEC treatment. Sensory-based details of what the client saw, heard, did, what other

people did, what happened etc. during the peak of these emotional experiences should be

identified for each event and utilized in PEC. In order to elucidate whether a special

circumstance (a time period, a specific situation, a significant other etc.) contains several very

pleasurable and masterful experiences the therapist can ask the client to remember all of the

peak experiences in chronological order. When one event and its central details have been

identified the therapist can ask what happened next that was very pleasurable or mastery-

laden to the client. The occurrences during which a client felt his/her strongest experiences of

pleasure or mastery should be utilized in PEC.

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During the course of PEC treatment the client may experience events in everyday life

that are more pleasurable and mastery-laden than the ones that are utilized in treatment. Such

present day experiences should be utilized in PEC treatment (e.g., imaginally relived) and

should replace other less reinforcing pleasure/mastery experiences that are currently utilized

in treatment. Stronger reinforcing experiences should be able to more effectively counter the

numbing symptoms, increase the trauma exposure tolerance and to weaken the trauma-related

respondent learning.

Pleasurable and mastery reliving as an avoidance behavior and dysfunctional reinforcer

Imaginal reliving of pleasurable/mastery experiences can function as an avoidance

behavior. If an individual intentionally utilizes pleasurable/ mastery experiences in order to

avoid an elicitation of trauma-related distress then the former may become negatively

reinforced. Conversely, if pleasurable/mastery experiences are utilized in order to weaken

fully elicited trauma-related distress then the former should be considered to be a coping

technique. Pleasurable and mastery experiences can function as reinforcers of avoidance

behaviors. This should particularly be the case when pleasurable/mastery experiences are

consistently relived in response to successful cognitive and behavioral avoidance behaviors.

The consequence may be that pleasurable/ mastery experiences positively reinforce cognitive

and behavioral avoidance behaviors. Negative reinforcement becomes positively reinforced.

The impact of the pleasurable and mastery reliving on a client’s cognitions

Trauma-related dysfunctional beliefs of oneself, other people and the world can

theoretically be positively reinforced by pleasurable/mastery experiences. If the pleasurable/

mastery reliving occurs subsequent to dysfunctional interpretations/ruminations about oneself,

others and the world the former may positively reinforce the latter. However, this may depend
 22

upon the content of the dysfunctional thoughts vs. the pleasurable/mastery reliving. If the

content of the dysfunctional thoughts and the incompatible experiences are unrelated then the

latter may function as a positive reinforcer of the dysfunctional thoughts. Conversely, if the

content areas overlap, then the pleasurable/mastery reliving may provide the traumatized

individual with contradictory evidence to the dysfunctional thoughts. In addition, even if the

content areas don’t overlap the pleasurable/mastery reliving may provide the traumatized

individual with incompatible respondent experiences to the trauma that may contradict the

trauma-related beliefs.

Imaginally relived pleasurable and mastery experiences may thus provide the

individual with evidence that contradicts trauma-related beliefs. An imaginal reliving of

events during which a person experienced other people as very trustworthy may strongly

contradict trauma-related beliefs of people as untrustworthy. Also, the dysfunctional belief

that oneself is an unworthy individual may be strongly contradicted by imaginal re-

experiences of appreciation or love from other people and of events in which the individual

experienced mastery. The dysfunctional belief that the world is an excessively dangerous

place (i.e., that other people are dangerous) may be strongly contradicted if the client’s

trauma-related respondent learning becomes weakened by incompatible respondent

experiences. As a result, the view of the world may become more realistic and much less

dangerous-laden.

Emotions that are re-experienced during the pleasurable and mastery reliving may

constitute strong evidence that contradicts a person’s negative interpretations of the numbing

symptoms. A consistent reliving of pleasurable and mastery experiences may effectively

counter the belief that he or she will never be able to enjoy valued activities, be close to other

people and experience emotions of happiness or joy.

 23

The pleasurable and mastery reliving in PEC may result in a behavioral activation

(i.e., approach behaviors) of valued activities and social transactions. A behavioral activation

in valued directions may constitute evidence that the person is a competent individual and that

his/her quality of life has increased. A decrease in avoidance behaviors towards trauma

reminders may constitute strong evidence that the traumatized individual is competent to face

situations that were previously avoided. A behavioral activation in valued activities that were

previously avoided because they elicited trauma-related distress may also constitute evidence

that the person is a competent individual. An establishment of natural reinforcers in everyday

life in combination with the extinction of trauma-related respondent learning may reciprocally

reinforce the generation of multiple evidences that may effectively counter dysfunctional

trauma-related beliefs.

The trauma response elicitation may generate an access to more reinforcing pleasurable and

mastery experiences and vice versa

One important topic is whether the trauma response elicitation enables an individual to

identify and relive increasingly more reinforcing pleasurable and mastery experiences, and

whether the pleasurable and mastery experiences enables the individual to more fully elicit the

trauma-related respondent learning. According to the present authors clinical experience there

may be a reciprocal influence between the two incompatible respondent learning mechanisms.

It is proposed that the pleasurable and mastery reliving may enhance a traumatized individuals

access to the most central trauma details and most distressing respondent responses.

Conversely, the trauma exposure may enhance an individual’s access to increasingly more

reinforcing pleasurable and mastery experiences that may be utilized in PEC in order to

weaken the trauma-related respondent learning more effectively.

 24

Questions that elicit most reinforcing pleasurable and mastery experiences from the outset

The initial theoretical assumption of the PEC treatment (Paunović, 2003) was that it is

possible to identify a client’s most reinforcing pleasurable and mastery experiences from the

outset of the treatment. For some clients this seems to be the case. However, other clients

don’t identify their most reinforcing pleasurable and mastery experiences until after several

sessions. One possibility may be that these individuals are not able to identify their most

reinforcing experiences until they have accessed trauma-related emotions on several

occasions. Other possibilities are that the questions that are used to identify a client’s most

reinforcing experiences have not been phrased correctly or that other questions may need to

be developed. At the present moment in time it is considered more functional to assume that

efforts need to be made in order to develop questions that may more effectively tap clients

most reinforcing experiences at the outset of a treatment. One criteria on which to judge the

usefulness of pleasurable and mastery experiences may be to ask a traumatized individual to

judge to what extent each experience strengthens the client to be confronted with the trauma.

Other criteria might be to ask the client to evaluate to what extent each experience motivates

him/her to become behaviorally activated in valued directions and how much the numbing

symptoms are countered. Finally, imaginally relived pleasurable and mastery experiences may

be evaluated on the basis of how fast and to what extent they can be relived fully after trauma

exposure. However, this is not possible to evaluate until after one or several sessions.

Emotional regulation deficits and pleasurable/mastery experiences

An individual’s avoidance of valued activities and interpersonal situations may be due

to emotional regulation deficits. Traumatized individuals may lack emotional regulation

skills. Such individuals may need to train themselves to focus on interpersonal goals instead

of feeling states triggered by trauma-related re-experiencing (Cloitre, 1998). An imaginal

 25

reliving of pleasurable and mastery experiences may help a traumatized individual to identify

and focus on the most valued interpersonal goals.

Pleasurable and mastery experiences as an alternative to mindfulness

Mindfulness has been described as a technique that can be used as an alternative to

ruminations and worries. In mindfulness an individual is trained to attend to present moment

experience (Hayes & Wilson, 2003; Teasdale, Segal, & Williams, 2003). The individual is not

to manipulate feeling states, but just to mindfully attend to them ‘here and now’. With respect

to the latter the present author proposes that it may be more therapeutically useful to attend to

reinforcing pleasurable and mastery experiences than to present moment experiences in

general. An attending to pleasurable and mastery experiences may strengthen an individuals

trauma exposure tolerance and counter the numbing symptoms whereas mindfulness training

is not intended to do so. Also, it is hypothesized that pleasurable and mastery experiences

have effectively weakened trauma-related respondent learning mechanisms in case outcome

studies (Paunović, 2002; 2003). It is difficult to conceptualize whether and in what way

mindfulness training could weaken respondent trauma responses.

Video movie scenes as a trauma exposure medium

Imaginal and in vivo exposure methods may in some cases be unable to match a

client’s most central trauma stimuli. Consequently, the elicited trauma-related respondent

responses may not match the client’s most distressing emotional responses during the trauma.

An alternative exposure medium such as video movie scenes that fully match the most central

stimuli of the client’s traumatic event may be able to effectively elicit trauma responses that

match those experienced during the peak of the trauma (e.g., Paunović, 2002). However, it is

crucial to present very distressing video movie scenes only when the client is able to tolerate
 26

such strong exposure medium. Imaginal exposure should be utulized in PEC during the first

sessions. Video movie scenes of violent events may be utilized after a couple of sessions

when the client’s trauma-related respondent learning has become weakened and the client has

become emotionally stronger to face such exposure medium.

A mastery imagery technique as exposure medium

If the traumatic experience is characterized by helplessness imagery a functional

cognitive response may be to replace trauma imagery with mastery imagery of the traumatic

situation. This is the purpose in imagery re-scripting (Smucker, Dancu, Foa, & Niederee,

1995; Smucker & Niederee, 1995). However, since imagery re-scripting is characterized by a

change in trauma imagery from an observer’s point of view the client may in actuality

dissociate from the traumatic experience. It is postulated that in order to increase mastery

experiences during trauma imagery it is important that the traumatized individual enacts

mastery behaviors or perceives how others come to rescue while the client fully relives the

traumatic experience. If a client is able to re-experience the trauma and enact mastery

behaviors he or she may experience an increase in trauma-related fear related to what could

have happened if the individual had resisted the violence. Such a technique may be utilized as

an exposure medium in order to elicit a client’s most distressing trauma-related fear.

Identification of neglected own needs

Traumatized individuals may neglect their own needs in the pursuit of satisfying other

peoples’ needs (e.g., Cloitre, Levitt, Davis, & Miranda, 2003). Newman, Castonguay,

Borkovec and Molnar (in press) state that interpersonal schemata are most amenable to

modification by exposure to corrective experiences when related emotions are activated.

Experiencing emotions increases client’s awareness of needs about which they were
 27

previously unaware and can guide them in choosing behaviors to meet these needs, as well as

behaviors to abandon. The trauma exposure and the pleasurable and mastery reliving in PEC

may help traumatized individuals to identify their own neglected needs. An identification of

neglected needs may motivate an individual to behaviorally activate him/herself in valued

directions in order to satisfy the needs.

Discussion

The primary purpose of the present article was to present a revised AFA model of

PTSD and to review important theoretical and methodological issues related to the

implementation of the PEC treatment for PTSD. In terms of the revised AFA model it is

assumed that respondent, cognitive and behavioral mechanisms have a reciprocal influence on

each other in the maintenance of PTSD. Furthermore, it is assumed that a representational

memory network of respondent, cognitive and behavioral mechanisms interact with

corresponding currently elicited factors. The role of respondent mechanisms in the AFA

model are particularly stressed since these factors are postulated to be the primary

mechanisms in the PEC treatment that is discussed in the second part of the paper. A number

of theoretical and methodological issues are outlined relevant to the implementation of the

PEC treatment on the basis of the author’s clinical experience. It is postulated that this should

help clinicians to implement the PEC treatment in accordance with its theoretical intentions.

Additional issues relevant to further developments of the AFA model and the PEC treatment

for PTSD will be discussed next.

Dysfunctional representational networks of respondent, cognitive and behavioral

mechanisms not specifically related to the development of PTSD may be elicited by the

traumatic experience. Pre-trauma dysfunctional representational networks may constitute

 28

generalized and specific psychological vulnerabilities to develop other anxiety disorders (e.g.,

Barlow, 2002) that may become elicited by the trauma and PTSD symptoms. That is, a

traumatic experience and PTSD symptoms may lead to the development of other anxiety

disorders in individuals with generalized and specific psychological vulnerabilities. This issue

will be shortly discussed for each type of vulnerability in terms of the AFA model.

A generalized psychological vulnerability to develop anxiety disorders may consist of

experiences with overcontrolling, intrusive parents during childhood (Barlow, 2002). A

family environment characterized by limited opportunity for personal control is associated

with future anxiety and negative affect. In addition, low warmth from parents may be related

to depressive symptoms in children (Barlow, 2002). In terms of the AFA model a traumatic

experience and PTSD symptoms may elicit a representational memory network of respondent

experiences of uncontrollability and beliefs of oneself as an incompetent individual.

Furthermore, the traumatic experience and PTSD symptoms may elicit respondently learned

emotional experiences of neglect by emotionally cold parents that in turn may exacerbate

PTSD numbing symptoms and depression. Respondently learned experiences of

uncontrollability and neglect that are established during childhood may be possible to counter

by respondently learned experiences of pleasure and mastery. The pleasurable/mastery

reliving should be conducted in the context of fully elicited respondently learned experiences

of uncontrollability and neglect.

A specific psychological vulnerability to develop panic disorder consists of caregivers

often modeling the “dangers” associated with somatic symptoms. Panic disorder patients

report a greater frequency of chronic illness and panic-like somatic symptoms in their

households when they were growing up than patients with other anxiety disorders or control

participants (Ehlers, 1993). Ehlers (1993) state that observing physical suffering can

contribute to the evaluation that somatic symptoms are dangerous and that special care is
 29

needed. Such experiences may lead to a tendency to focus anxiety on bodily sensations and to

develop beliefs about the dangers of these sensations. In terms of the AFA model a traumatic

experience and PTSD symptoms may elicit a representational memory network of

respondently learned emotional experiences of chronic illness and modeling experiences of

panic like symptoms. An elicitation of such a memory network may lead to the development

of comorbid panic attacks or panic disorder with/without agoraphobia. A plausible hypothesis

is that it may be possible to utilize incompatible respondent experiences of pleasure and

mastery in order to weaken respondently learned panic symptoms. One client relived several

interpersonal pleasurable experiences that were utilized in order to weaken her imaginally

relived first panic episode that occurred in a hospital two hours after her traumatic experience.

Her specific psychological vulnerability consisted of experiences with her father who had

suffered from a coronary heart disease that subsequently caused him a fatal heart attack. Her

PTSD and panic attacks with agoraphobia decreased clinically significantly after PEC

treatment.

A potential specific psychological vulnerability to develop social phobia may consist

of parents of socially anxious children who spend a great deal of time discussing the potential

threatening nature of social situations with their children and reinforce their children’s

tendency to avoid these situations (Barett, Rapee, Dadds, & Ryan, 1996). People with a

psychological vulnerability to develop social phobia who experience a trauma and develop

PTSD symptoms may also develop social phobic symptoms. A traumatic experience and

PTSD symptoms may elicit a representational network of respondently learned social fear and

concomitant dysfunctional cognitive and behavioral responses. It may be possible to weaken

respondently learned social fear with respondently learned social experiences of pleasure and

mastery. In order to weaken social fear incompatible respondent social experiences should be

elicited in the context of fully elicited social fear.

 30

A specific psychological vulnerability in OCD is commonly derived from an early

broad sense of responsibility encouraged during childhood and rigid codes of conduct or duty

required in school or religious education (Steketee & Barlow, 2002). Extremely high

standards imposed during childhood and/or excessively critical reactions from authority

figures may contribute to perfectionistic attitudes, feelings of guilt, and extreme beliefs in

responsibility. According to Steketee and Barlow (2002) such historical experiences are likely

to have special influence when the person experiences an actual increase in duties and

responsibility, as in stressful life changes. A traumatic experience and PTSD symptoms may

elicit such pre-trauma representational memory network characterized by respondent

experiences of excessive responsibility and emotional reactions to critical authority figures.

This may result in an attempt to compulsively neutralize distressing trauma-related intrusions

(cognitively and/or behaviorally). If the compulsions are excessive and consistent over time a

co-morbid diagnosis of PTSD and OCD may be warranted. In terms of the AFA model a

respondent learning of excessive responsibility and reactions to critical authority figures may

be weakened by incompatible emotional experiences. Pleasure and mastery experiences may

be able to weaken both traumatic intrusions and respondent experiences of reactions to

authority figures. In order to accomplish this incompatible respondent learning mechanisms

must be fully elicited in the context of fully elicited trauma-related distress and learned

emotional reactions to authority figures.

Individuals who develop generalized anxiety disorder (GAD) often report role-

reversed/enmeshed relationships during childhood (Borkovec & Newman, 1998). As children

people with GAD tended to take care of the parent rather than the parent taking care of the

child. These clients also report greater unresolved feelings of anger and vulnerability toward

their primary caregiver. Worry in people with GAD may function as a means of anticipating

the needs of, and threats to, significant others in the pursuit of satisfying interpersonal needs.
 31

A traumatic experience and PTSD symptoms may elicit a representational memory network in

such individuals consisting of respondently learned experiences of excessive care taking and

unresolved feelings toward their primary caregiver. In terms of the AFA model pleasurable

and mastery experiences may be able to weaken both trauma-related intrusions and

respondently learned experiences of excessive care taking and unresolved negative feelings

toward their caretaker. In order to accomplish this the incompatible respondently learned

experiences should be elicited in the context of fully elicited intrusion-related distress and

respondently learned experiences of care taking and unresolved negative feelings toward their

caretaker.

The traumatic experience may be characterized by a situation in which the individual

felt hopeless and gave up completely in her mind in terms of thinking how to minimize or

escape from the dangerous situation. This cognitive style is termed as mental defeat and is

associated with inferior results in exposure therapy (Ehlers et al., 1998). An interesting

question is whether the inferior results in exposure treatment is due to the cognitive style of

mental defeat or to respondently learned emotional experiences that may underlie the

generation of such cognitions. If respondently learned emotions generate the cognitive style

of mental defeat then a prolonged pleasurable and mastery reliving may be useful in order to

counter the trauma-related respondent learning and the cognitive style of mental defeat.

Conversely, if the cognitive style of mental defeat is the cause of the inferior results in

exposure therapy, then cognitive techniques may be useful in order to combat this

dysfunctional cognitive style. In such a case a functional change in the cognitive style of

mental defeat should lead to improvements in the mental defeat experience.

The phenomenon of transfer of excitation (Taylor, 2000) may be useful to have in

mind when an imaginal reliving of pleasurable and mastery experiences is conducted. A

rationale for using pleasurable/mastery experiences that induce low arousal (e.g., calm,
 32

relaxation etc.) before trauma exposure is that they may lower an individual’s baseline level

of physiological responding. On the other hand, pleasurable/mastery experiences that induce

high arousal may be useful when one wants to accomplish a transfer of excitation from the

pleasurable to the trauma reliving. Such process may be particularly useful if the client has

difficulties in accessing the most central trauma details.

Cognitive and behavioral techniques can be utilized in order to reinforce the

respondent re-learning that is hypothesized to take place in PEC. Functional interpretations or

verbal statements may reinforce imaginally relived pleasurable and mastery experiences (e.g.,

“I am a worthy and competent individual”, “other people are trustworthy”). A weakening of

trauma-related respondent learning provides information that can be verbally reinforced (“I

am no longer afraid”, “the world no longer seems dangerous”). The pleasurable and mastery

reliving may provide information to clients about what their most valued activities are.

Behavioral activation in valued directions is useful in helping clients create a behavioral

lifestyle that provides them with natural reinforcers in everyday life (Martell, Addis, &

Jacobson, 2001).

Clients can utilize questions that may help them to focus on and relive pleasurable and

mastery experiences in everyday life. Such questions should include clients’ most valued

emotional experiences. An individual that labels his/her most valued emotion as happiness

can utilize questions that recall self-relived emotional experiences of happiness (e.g., “what

am I most happy about in my life?”). The purpose should be to re-experience and reinforce

emotions of happiness in everyday life. Same types of questions can be utilized that include

other emotional contents. A person that values experiences labeled as security and love may

utilize questions that recall self-relived experiences of security and love. Such questions can

be utilized on repeated occasions in everyday life in order to reinforce valued emotions.

Additional questions may be utilized in order to further elaborate on the valued experiences
 33

and to elicit more central details from these experiences (e.g. “what happened during the

event that made me most happy?”, “what further details do I remember that made me most

happy?” etc.). Sensory-specific questions should be utilized in order to extract central stimuli

details (“what did I see, hear, do, what did other people do?” etc.). Valued experiences may

also be reinforced by questions that help a person focus on emotions of pleasure and mastery

(“how do I feel?”). All these questions should be repeatedly utilized with the purpose of

eliciting valued emotional experiences in everyday life. An emotional reliving of valued

experiences may increase an individual’s attempts in valued directions in life. Such a reliving

may also constitute contradictory evidence to dysfunctional thoughts about oneself, others and

the world. In addition, incompatible respondent experiences in everyday life may counter a

traumatized individual’s numbing symptoms and intrusions and may increase a person’s

trauma exposure tolerance.

The purpose of the present article was to present a revised AFA model and to discuss

important theoretical and methodological issues relevant to the PEC treatment. In the

discussion section additional issues were outlined that may also be useful in a further

development of the AFA model and the PEC treatment. Future endeavors should focus on

developing the AFA model and the PEC treatment in line with the issues that have been

outlined and discussed in the present paper.

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